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James Stephen KEEN · Prevention of Future Deaths report View report

2 Jan 2025 West London L. Brown

James Stephen KEEN was found deceased in his room at supported accommodation on 8 December 2023. He had a history of severe mental ill-health and substance abuse, and the inquest conclusion recorded a drug-related death involving the cardiotoxic effects of methamphetamine and sildenafil. Concerns included confusion and inadequate documentation about physical health observations by untrained support workers, a broken thermometer, and a lack of evidence of appropriate training or competency checks.

Gemma Suzanne Marshall · Prevention of Future Deaths report View report

2 Jan 2025 West Yorkshire (Western) S. Eccleston

Gemma Suzanne Marshall underwent private gastric-band surgery in 2020, attended hospital with black vomiting and lower abdominal pain in March 2024, and died after the band slipped. The report raises concern that an outsourced radiologist failed to identify and report the slipped band on a CT scan, contributing to a failure to refer her to bariatric specialists. It also identifies wider concerns about radiologists’ familiarity with slipped bands and reliance on non-specialist or outsourced reporting during staff shortages.

David Joseph Crompton · Prevention of Future Deaths report View report

31 Dec 2024 West Yorkshire Eastern K. McLoughlin

David Joseph Crompton, who had epilepsy, was left without his prescribed Tegretol for approximately 10 days in April 2024 and again in December 2024. His falls in both periods occurred when he was without the medication, and the inquest recorded a fall downstairs on 13 December 2024, with causes of death including hypoxic ischaemic encephalopathy, out-of-hospital cardiac arrest and cervical spine injury. The principal concerns were delays in supplying essential anti-epileptic medication, reliance on family members to seek alternative supplies, and the absence of clear systems for managing medication shortages.

Denise Ellen Johnson · Prevention of Future Deaths report View report

30 Dec 2024 Suffolk D. Sharpstone

Denise Ellen Johnson was admitted to hospital with abdominal pain and jaundice, underwent ERCP with stent insertion, and subsequently developed severe acute necrotising pancreatitis. Despite intensive supportive care, drainage, antibiotics and other treatment, she died on 24 November 2022; the inquest recorded multi-organ failure, severe E. coli septicaemia, pancreatic necrosis and ischaemic bowel perforation. The principal concerns were delayed notification and formal review of serious ERCP complications, inadequate communication with the next of kin and family about management plans, and unclear consultant cover during unexpected leave, each identified as posing a significant risk to patient safety.

Michael Ramon JERVIS · Prevention of Future Deaths report View report

30 Dec 2024 Cornwall and Isles of Scilly G. Davies

Michael Ramon Jervis died at Royal Cornwall Hospital Truro on 16 July 2023 from neutropenic sepsis, a recognised complication of chemotherapy for testicular cancer. The report found a 20-hour delay in administering antibiotics after observations indicated they were required, and identified the absence of a digital alert that could have alerted staff to implement the Sepsis Six bundle.

Paul Taylor · Prevention of Future Deaths report View report

24 Dec 2024 Nottinghamshire N. Hartley

Paul Taylor was under police investigation and, within a fortnight of learning that criminal charges had been authorised, intentionally took a large quantity of prescription medication and was found deceased at home on 3 January 2024. The report raises a concern that suspects interviewed voluntarily are not automatically referred to mental health services, with only welfare assessments by the investigating officer and no healthcare involvement.

Daniel Isaacs · Prevention of Future Deaths report View report

24 Dec 2024 Nottinghamshire N. Hartley

Daniel Isaacs died after losing control of an electric scooter, colliding with the road surface and sustaining a serious head injury. The report raised concern that electric scooter riders and cyclists are not required to wear helmets, creating a risk of death in collisions involving people not wearing protective headwear.

David Christopher Peter Lodge · Prevention of Future Deaths report View report

23 Dec 2024 East Riding and Hull E. Steele

David Christopher Peter Lodge, who had a learning disability, was found unwell beside his deceased father after lying for up to four days and died at Hull Royal Infirmary on 13 January 2022 from bilateral pneumonia. Concerns included inadequate pain assessment, no chest examination, failure to appropriately escalate high NEWS2 scores or transfer him to intensive care, and missed opportunities to learn from the death through a serious incident investigation.

William Charles Hare (Bill) · Prevention of Future Deaths report View report

23 Dec 2024 Essex R. Mundy

William Charles Hare (Bill) presented with abdominal and left loin pain in November 2022 and was subsequently diagnosed with metastatic urothelial cancer. He died in a hospice on 23 January 2024 after delays in diagnosis and treatment, including delays in biopsy, specialist review, MDT consideration, hospital transfer and scan results. The report identified systemic and procedural errors and ineffective coordination between Basildon and Southend Hospitals as substantive concerns.

NIGEL WILLIAM SWEET · Prevention of Future Deaths report View report

23 Dec 2024 Cornwall and Isles of Scilly G. Davies

Nigel William Sweet, aged 63, died on 7 March 2024 on the A38 after losing control of his motorcycle while attempting to overtake in wet conditions and being struck by an oncoming vehicle. Concerns included the higher proportion of collisions on this stretch of road, associated with its single-carriageway layout and occasional creeper lanes, and the absence of approved funding for a proposed average-speed-camera safety scheme.

David John Haw · Prevention of Future Deaths report View report

20 Dec 2024 Dorset R. Griffin

David John Haw was thrown from a support RHIB after it collided with a buoy in Poole Harbour at approximately 30 knots on 2 May 2022. He was recovered from the water on 14 May 2022, and the inquest recorded drowning and concluded unlawful killing. The concerns include differing safety requirements for pleasure and commercial vessels, alcohol use by pleasure-vessel helms, the absence of requirements for lifejackets on some vessels, and the use and regulation of support boats at sailing events.

Haydar Jefferies · Prevention of Future Deaths report View report

20 Dec 2024 Surrey C. Topping

Haydar Jefferies was detained at HMP Coldingley and developed severe depression and psychosis before self-ligaturing in his cell on 1 March 2023; he was resuscitated but died at hospital on 5 March 2023 from hypoxic brain injury and pneumonia. The principal concerns included failures to record and share risk-relevant information, refer him promptly to mental health services, provide an adequate mental health assessment and obtain appropriate clinical care and supervision during his acute deterioration.

Eleanor Curley-Bennett · Prevention of Future Deaths report View report

20 Dec 2024 Staffordshire and Stoke-on-Trent E. Serrano

Eleanor Curley-Bennett, aged three weeks, stopped breathing at a family-friendly music festival on 18 August 2023 and died at hospital in the early hours of 19 August 2023. The report identified a lack of correctly sized basic life-support equipment, intubation equipment, and suitable prefilled diluted adrenaline for a baby of her age.

Antony Williamson · Prevention of Future Deaths report View report

20 Dec 2024 Manchester South A. Farrow

Antony Williamson experienced chronic pelvic pain and associated mental health difficulties, including increasing suicidal thoughts, before leaving home on 19 December 2023 and entering cold water. His body was found in the River Mersey on 17 March 2024, and the inquest concluded that he died from dry drowning and took his own life while experiencing hopelessness about the investigation and treatment of his pelvic pain. The report identified a lack of liaison and communication between the medical and mental health specialties involved in his care, with no formal framework to facilitate inter-specialty communication in complex cases.

Edith Theresa PYE · Prevention of Future Deaths report View report

20 Dec 2024 Worcestershire D. Reid

Edith Theresa PYE sustained a fracture after rolling from her bed at Chandler Court Care Home on 29 March 2024 while receiving personal care from one carer instead of the required two. She underwent an above-knee amputation, developed a chest infection and pulmonary emboli, and died at the care home on 28 April 2024. Concerns included ambiguous care-plan and handover information, inadequate staff awareness and compliance, lack of auditing, and weaknesses in the internal investigation.

Oliver James WINSON · Prevention of Future Deaths report View report

20 Dec 2024 Norfolk S. Goward

Oliver James Winson, a 33-year-old man with a history of drug misuse and a referral for adult ADHD assessment, was found deceased at home on 10 June 2024. Toxicology confirmed cocaine use before death, and the medical cause of death was cocaine toxicity. The principal concern was that lengthy adult ADHD waiting lists left at-risk patients without treatment or monitoring, potentially allowing deterioration, harmful behaviour and death.

Andrew Michael Lewis · Prevention of Future Deaths report View report

19 Dec 2024 Berkshire H. Connor

Andrew Michael Lewis died at home on 7 May 2024 after calling 111 with weakness in his legs and an earlier fall. An ambulance arrived about 10 hours after his first call, although the call had been categorised as requiring attendance within two hours; the report states there was simply no ambulance available to send earlier. The inquest recorded the cause of death as acute on chronic gastrointestinal haemorrhage, bleeding oesophageal varices, alcoholic liver cirrhosis, and low volume subdural haemorrhage, with the conclusion of an alcohol-related death contributed to by head injury.

Eleanor Hazel ALDRED-OWEN · Prevention of Future Deaths report View report

18 Dec 2024 Liverpool and the Wirral H. Rimmer

Eleanor Hazel ALDRED-OWEN was admitted for elective craniofacial surgery and developed respiratory distress after the procedure. She suffered a cardiac arrest associated with a right-sided tension pneumothorax, and died after life-sustaining measures were withdrawn following catastrophic hypoxic-ischaemic brain injury. The report raised concern that radiographers’ standard operating procedures did not provide for escalation of care or an urgent arrest call when there were clear signs of imminent danger to life.

Sylvia Margaret Louisa SAVAGE · Prevention of Future Deaths report View report

18 Dec 2024 County Durham and Darlington J. Thompson

Sylvia Margaret Louisa Savage died on 25 April 2023 at the University Hospital of North Durham from bronchopneumonia, following a fall from her bed at Redwell Hills Care Home on 18 March 2023 and subsequent injuries and decline in health. The concerns included unclear fall-reporting arrangements, ineffective monitoring of her mobilisation, inadequate post-fall medical assessment, missing or insufficient care records, and failure to promptly reassess her care plan after falls.

Susan Marie Karakoc · Prevention of Future Deaths report View report

17 Dec 2024 Nottinghamshire A. Bewley

Susan Marie Karakoc collapsed at home on 1 December 2023 and died in hospital the following day after suffering a hypoxic brain injury. The report states that she obtained prescription medications from online sources selling medicines off-label, and that toxicological examination identified toxicity associated with the chain of events leading to her death. Concerns included the ready availability of such websites through search engines, inadequate monitoring of online medication supply chains, and ineffective detection of financial services supporting criminal enterprises.